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Background  Ventilator-associated pneumonia (VAP) is a common nosocomial infection in pediatric intensive care units (PICUs), but its effect on clinical outcomes in resource-constrained settings is underexplored. Understanding these effects is essential for improving care. Objective Our aim is to evaluate the impact of VAP on clinical outcomes and identify baseline factors associated with VAP among mechanically ventilated pediatric patients. Methods This retrospective cohort study was conducted at the PICU of Jinnah Hospital, Lahore, from January to June 2023. Children aged 1 month to 18 years who required mechanical ventilation for at least 48 hours were included. We categorized patients into VAP and non-VAP groups based on CDC/NHSN 2023 criteria. We compared baseline characteristics and clinical outcomes. Categorical variables were analyzed using the chi-square test. Continuous variables were compared using the Mann-Whitney U test. Results Among 150 patients, 50 (33.3%) developed VAP. Patients with VAP had a significantly longer median duration of mechanical ventilation (12.0 days, IQR: 9.0-16.0) compared to non-VAP patients (5.0 days, IQR: 4.0-6.0; p < 0.001) and a longer median PICU stay (14.0 days, IQR: 10.0-18.0 vs. 7.0 days, IQR: 6.0-8.0; p < 0.001). Prior antibiotic use was documented in all 50 (100%) VAP patients compared to 17 (17.0%) in the non-VAP group (p < 0.001). Mortality was higher in the VAP group (16/50 patients, 32.0%) compared to the non-VAP group (0/100 patients, 0.0%; p < 0.001). Daily oral care with chlorhexidine was strongly protective (risk ratio = 0.46; 95% CI: 0.34-0.63). Standard multivariable logistic regression could not be performed due to the complete separation of data; therefore, Firth penalized logistic regression was performed using R. Conclusion VAP is linked to longer ventilation, extended PICU stay, and higher mortality. These findings stress the need for targeted preventive measures and improved ventilatory practices in resource-constrained PICUs.